He is sprawled across the walkway when they first arrive, his face flecked with vomit, his skin tinged blue. He has overdosed, but his body is still warm, his heart still beating. He looks to be maybe 30.

The firefighters quickly clear his airway and press a bag valve mask over his face to facilitate breathing. A pulse oximeter affixed to his right ring finger tells the first responders that his oxygen saturation level is at 90 per cent; a normal level is generally above 95.

Firefighter Brandon Davies draws up 0.4 milligrams of naloxone – a drug that reverses the effects of an opioid overdose – and injects it into a fleshy part of the man's lower abdomen. Within a couple of minutes, the man wheezes, then coughs.

"There we go," says one of a handful of first responders now crouched around him. "Big cough, okay?"

Five minutes after the first injection of naloxone, they administer a second. The man's oxygen saturation has reached 98 per cent. Paramedics have now arrived on the scene and are suctioning vomit from the man's airway with a portable unit.

All the while, several people sitting nearby look on, unfazed. One woman is preparing a hit.

An elderly man approaches the group. "There's a guy right around the corner who looks like he's in a lot of trouble as well," he tells them.

It's 3:45 p.m. on a Tuesday, and the sun is shining.

Vancouver Fire and Rescue Services' Fire Hall No. 2 is located in the heart of the city's sleepless Downtown Eastside, a stone's throw from Insite, North America's only public supervised injection site, on a street full of social-service providers. It sits across from the Provincial Courthouse and next to a strip club.

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It has long been one of the busiest fire halls in North America, but its proximity to a bustling open-air drug market, in the province hardest hit by the fentanyl crisis, has sent it into overdrive.

From January through September, 555 people died of illicit drug overdoses in British Columbia – the highest annual death toll in 30 years of record-keeping. Fentanyl, the powerful synthetic opioid that is being cut into a growing percentage of street drugs, was a factor in about 60 per cent of those deaths. In all, around 700 people are projected to die of illicit drug overdoses in B.C. by year's end.

At Fire Hall No. 2, monthly calls for service have doubled in the past four years, surpassing 1,000 as of this summer. For individual firefighters, that can translate to 20 calls per 10-hour day shift, or 30 calls per 14-hour night shift, Lieutenant Mike Hatcher said.

As fentanyl-related overdoses climb in B.C., firefighters – usually first on the scene of medical calls – are finding themselves more often rescuing people not from burning buildings or crashed cars, but from the brink of a fatal overdose.

Fire departments, beginning with Vancouver and Surrey, began carrying naloxone this spring as part of a provincial strategy to combat overdose deaths. In the first six months, Fire Hall No. 2 members administered it 32 times – five times as many as the next Vancouver fire hall.

"When I came down here in '98, we'd get maybe one overdose a set [four shifts]," Lt. Hatcher said in an interview at the fire hall. "Now, you're getting close to half a dozen a shift, maybe more. Maybe 20 to 30 a set."

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"When I first started, breathing for somebody was a big deal," said Mr. Davies, the firefighter. "It was something you remembered every day: 'Holy, I got to breathe for somebody.' Now, we'll do it three times a day. It's totally normal now. It's weird."

They admit that it can take a toll.

"Mentally, it's discouraging to see how it's being handled by the city, how open it is, to see another human being in that state," firefighter Ian Hawksbee said. "I'm more than happy with the profession I've chosen – you get to help people every day, which is amazing – but it's disheartening sometimes when you go to the same person more than once in a day for the same thing. It's tough. It weighs on you. It's sad."

Since Vancouver and Surrey fire departments began carrying naloxone this spring to treat overdose victims, Fire Hall No. 2 members have administered it 32 times.

How firefighters are fighting fentanyl

Calgary

The Calgary Fire Department received 393 overdose calls last year and is projected to get a total of more than 480 in 2016. In response, the department is developing a program to train members on how to administer intranasal naloxone, which it hopes to have approved by December.

“I think it’s a great fit for emergency responders [to be able to administer naloxone],” Deputy Fire Chief Joe Zatylny said. “Fifty per cent of our calls are medical calls and we’re well situated and well trained to be able to respond first to a medical call. This is something that will help us affect the lives of Albertans.”

As of mid-October, the Calgary Fire Department had recorded 82 calls related to fentanyl this year, compared with 58 for all of 2015.

Winnipeg

From January through July, Winnipeg firefighters and paramedics responded to 964 reported overdose or poisoning calls, with 322 people requiring naloxone. This compares with 1,556 such calls in 2015 and 1,328 in 2014.

Victoria

From January through September, the Victoria Fire Department responded to 368 overdose calls – an average of 41 such calls per month. Members began carrying intramuscular naloxone in May, but have used it just once since. The department has also undergone training on the dangers of fentanyl exposure on calls and recently purchased intranasal naloxone to protect its members.

As of Sept. 30, 44 people had died of illicit drug overdoses in Victoria – the city’s highest annual death toll in a decade.

A couple of hours before the overdose on the walkway, the crew responded to a call of an unresponsive person found in a back alley.

From steps away, it is impossible to discern whether the slight body – curled on its side, lost in a flimsy blue windbreaker, a black tuque pulled down low – is that of a man or a woman, an adult or a child.

"Take two deep breaths there, Stacy," a first responder says sternly.

The woman's face is pressed to the pavement, not far from a dumpster dripping various fluids. Scattered around are a flattened sandwich wrapper, cigarette butts and the little orange syringe caps that are as commonplace in these alleys as leaves on a fall day.

It isn't immediately clear what happened, but she's slowly coming to. They prop her up and she bursts into tears. Two other first responders join and they carefully lift her onto a stretcher.

"Stacy, I'll get a hold of your boyfriend and let him know you're going to hospital," a friend calls from down the alley.

Sometimes people who have been revived are grateful; sometimes they are in disbelief. Some become angry, upset that the naloxone has ruined a high they paid money for, or that their remaining drugs have been disposed of. Some are indifferent and just want to leave: "I'm outta here."

For Jamie Grant, a B.C. paramedic who has worked in the Downtown Eastside since 2010, there are two kinds of overdose calls that stick out to him the most.

The first is when the victim comes to and cries. "When they cry, it means that they understand what happened," he said in an interview at an East Vancouver coffee shop. "[I say], 'How can I help you? Do you need resources for a safe place to stay? Can I put you in touch with a counsellor? What can I do for you?' "

The second is when he knows the victim is long gone. Oftentimes, these events take place in single room occupancy buildings, where a person overdosed at night and wasn't discovered until the next morning.

"By the time we get there, they've been dead for eight hours," Mr. Grant said. "Those stick out because the people who are calling are like, 'You're going to come and fix it? You're going to give them [naloxone]?' And, of course, it's always their buddies who find them."

B.C. Emergency Health Services responded to 12,260 suspected overdose or poisoning events provincewide in 2015 – the most in at least five years. About 3,700 of those calls were in the Vancouver Coastal Region.

As of the end of August, paramedics responded to about 11,500 suspected overdose or poisoning events. In both last year and this year to date, paramedics administered naloxone just over 3,000 times.

Brandon Davies, right, disinfects the boots of his lieutenant.

Firefighters are currently stationed at the Downtown Eastside fire hall for 18 months at a time – much shorter than the standard three- to five-year terms usually worked at other Vancouver halls. But Fire Chief John McKearney said the service is looking to reduce that further, to 12 months, to avoid burnout.

As well, he said the fire hall recently began borrowing units from less busy halls to mitigate call volumes during the week when welfare cheques are distributed – the busiest days of the month.

In recent years, the city has also become more accommodating of members who need help with stress management, mental health or exhaustion.

"That's when people have got to say to their supervisor, 'Listen: I need some help here' – which a lot of members do," Lt. Hatcher said. "That's when the city will accommodate them. There's still that mentality out there, 'I'm tough, I can take it' – there are still a few people out there like that – but the city will accommodate you if you ask for help."

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